Discussion
The overall summary of guidelines for management of COVID-19 in
pregnancy across different professional societies and institutions are
consistent; with some variation in the strength of recommendations.
Global societies such as WHO and CDC have a similar approach to their
guideline publication; keeping the recommendations broad so it can be
utilized across all shapes and sizes of healthcare institutions. Many of
their recommendations overlap with those for the general population and
they provide great resources to guide readers to perinatal societies for
more specific questions.
International perinatal societies including ACOG, RCOG, SMFM, ISUOG,
CNGOF, ISS/SIEOG and public institution CatSalut, all share similar
recommendations answering questions that are very specific to the care
of pregnant patients- from prenatal screening, antepartum care, details
of intrapartum care during different stages of labor in emergency and
non-emergency settings, to postpartum care and follow up. The guidelines
put forth by SMFM (United States) are most specific to the care of high
risk pregnancies; given their expertise in this field. ACOG (United
States) and RCOG (United Kingdom) summarize recommendations that are
suitable for lower risk pregnant patients. CNGOF (France) and ISS/SIEOG
(Italy) and CatSalut (Barcelona), give some practical recommendation for
the management of infected pregnant women. ISUOG (International)
provides more information specific to managing and cleaning ultrasound
equipment–an essential tool in the care of pregnant patients which
could be a vector for disease transmission if sanitization is not a
priority.
The consensus amongst the all perinatal societies encourages all
institutions to transition to telehealth when appropriate and limit the
number of face to face visits. Ultrasounds and antenatal surveillance
should be performed only if medically indicated. The use of antenatal
steroids for fetal lung maturation for patient at high risk of preterm
birth within 7 days should still be performed if pregnancy is between 24
0/7 to 33 6/7 weeks gestation; but should be avoided during late preterm
of 34 0/7 to 36 6/7 weeks gestation. All institutions should set up a
designated screening area, labor and delivery rooms, and operating rooms
for COVID-19 patients. All patients should be screened for symptoms,
travel history, contact history and follow the appropriate algorithm
provided to guide need for performing real time PCR test. As the numbers
of testing sites and resources have increased over the past few weeks,
there should be consideration for screening every pregnant patient being
admitted if feasible. Societies recommend only one consistent support
person to be present during delivery. Mode and timing of delivery should
still be performed on the basis of routine obstetric indications.
Aerosol generating procedures such as use of oxygen and forceful pushing
should be avoided to protect everyone in the delivery room. Appropriate
PPE should be donned by patients and healthcare workers during all
interactions. N95 should be worn during aerosol generating procedures[5]. Currently, mother and baby separation and
discouraging breastfeeding are not advised unless the mother is acutely
ill. However, mothers are advised that breast pumping should be
considered over breastfeeding and to wash hands before handling baby,
touching pumps or bottle, avoid coughing while baby is feeding, consider
wearing face mask while feeding or handling baby. If a breast pump us
used, clean properly after each use, and routinely clean all surfaces
that are touched. The length of hospital stay should be decreased to 1
day for vaginal delivery and 2 days for cesarean delivery to limit time
of exposure for patients and healthcare workers in the hospital while
also increasing bed capacity. Once discharged, patients are advised to
continue social distancing, and routine postpartum visits can be
conducted using telehealth. The method of telehealth should be
individualized based on institution resources and availability.